=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679714091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREA L. SMITH MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2009
-----------------------------------------------------
Last Update Date | 05/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 785 OHIO AVE SUITE 1D
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-624-5485
-----------------------------------------------------
Fax | 662-624-8890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 785 OHIO AVE SUITE 1D
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-624-5485
-----------------------------------------------------
Fax | 662-624-8890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANDREA L SMITH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 662-624-5485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 09185
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------